A push for 90-90-90: Initial treatment with INSTI-based regimens against HIV-1 infection

Abstract

In recent years, the global scenario of HIV infection has dramatically ral treatment with b350 CD4 cells/mm, reflecting the prescription recommendations followed until 2015, when the INSIGHT START trial changed with the widespread implementation of antiretroviral treatment (ART) and the aim to reach the goals of the UNAIDS initiative “90-90-90: Treatment for all” (www.unaids.org/en/resources/909090) by 2030. Furthermore, ground-breaking scientific evidence has revolutionized the life of people living with HIV/AIDS (PLWH). Undetectable equals untransmittable (U=U) is one of the most important messages since the rise of HIV epidemic with the power to reduce the stigma related to infectiveness [1]. Among the potential strategies to be implemented to end HIV epidemics, treatment as prevention is the one with the strong scientific evidence [2]. In their work Zhu J et al have formalized a model assessing the potential impact of integrase strand-transfer inhibitor (INSTI)-containing regimens in reducing onward HIV transmissions in British Columbia [3]. By applying two previously described models of HIV transmission [4,5], which are based on HIV-RNA viral load and the natural history of HIV infection (early vs chronic vs late), the authors demonstrated how the use of INSTI-based regimens in naïve patients could potentially reduce the risk of HIV transmission when compared to non INSTI-based regimens in their cohort. In particular, a HIV transmission risk reduction of 25%, according to the model by Fraser C et al, has been estimated for gay, bisexual and other men who have sex with men (gbMSM) starting an INSTI-based regimen with a viral load ≥5log10 copies/mL irrespectively of HIV stage [5]. Authors concluded that INSTI-based regimens have the potential to avert onwardHIV transmission by achieving a fast virologic suppression, in particular among gbMSM with pretreatment high viral load. Although these data are sound, some potential pitfalls should be acknowledged to correctly interpret the findings reported by Zhu J et al.